Breast Surgery (Mastectomy / Lumpectomy Residuals) C&P Exam Prep

Surgical Site and Scar Assessment

What it measures: Documents the presence, size, location, and characteristics of surgical scars from mastectomy or lumpectomy, including whether scars are painful, unstable, adherent, or cause disfigurement.

What to expect: The examiner will visually inspect and palpate the surgical scar(s). They will note scar dimensions, tenderness, mobility, and whether the scar is hypertrophic, keloidal, or adherent to underlying tissue. They will also assess any chest wall or breast disfigurement.

Pain considerations: Scar pain should be described at its worst - burning, stabbing, or aching quality, radiation of pain, aggravating factors (clothing contact, movement, temperature changes), and how frequently it occurs. Chronic scar pain can support a separate painful scar rating under DC 7804.

Lymphedema Assessment

What it measures: Evaluates the presence and severity of lymphedema (swelling) in the arm, hand, or chest wall following axillary lymph node dissection or sentinel node biopsy, which is a ratable residual under DC 7626 notes.

What to expect: The examiner may measure circumference of both arms at multiple points to compare, assess pitting vs. non-pitting edema, evaluate skin texture changes (fibrosis, peau d'orange), and ask about history of cellulitis or infections related to lymphedema.

Pain considerations: Lymphedema-associated pain, heaviness, tightness, and aching should be described in full detail. Describe your worst days - when the arm is most swollen and painful, and what activities are impossible or severely limited on those days.

Upper Extremity Range of Motion (Shoulder, Arm, Wrist)

What it measures: Evaluates limitation of arm, shoulder, and wrist motion resulting from mastectomy, reconstruction, lymphedema, radiation fibrosis, or harvesting of muscles for reconstruction - all ratable residuals under DC 7626.

What to expect: The examiner will test active and passive range of motion of the shoulder (forward flexion, abduction, external/internal rotation), elbow, and wrist. They should also assess weight-bearing and non-weight-bearing ranges. Pain with motion, end-range pain, and functional limitations will be noted. Goniometer may be used.

Pain considerations: Per DeLuca v. Brown, the examiner must consider pain, fatigue, weakness, and incoordination during repetitive use and flare-ups - not just a single measurement at rest. If your shoulder or arm is more limited after activity or on bad days, explicitly state: 'My range of motion is significantly worse after I use my arm, and during flare-ups I cannot lift my arm above shoulder height.'

Grip Strength Testing

What it measures: Documents loss of grip strength in the affected hand/arm as a residual of mastectomy-related lymphedema, nerve damage, or muscle harvesting for reconstruction.

What to expect: The examiner may use a dynamometer or assess grip strength clinically. Both hands will typically be compared. The examiner should note whether weakness is due to lymphedema, nerve compromise (from axillary dissection), or muscular changes.

Pain considerations: Pain during grip activities is relevant - describe the quality (sharp, burning, aching), when it occurs, and how long it takes to resolve after activity. Weakness that worsens with repeated use is a DeLuca factor that must be documented.

Sensation Testing

What it measures: Assesses loss of sensation in the chest wall, breast area, axilla, or arm - a specifically listed ratable residual under DC 7626 for surgical residuals.

What to expect: The examiner will test light touch, pinprick, or temperature sensation over the surgical area, chest wall, and along the inner arm (intercostobrachial nerve distribution). They will document areas of numbness, hypersensitivity, or dysesthesia.

Pain considerations: Post-mastectomy pain syndrome (PMPS) is characterized by chronic neuropathic pain in the axilla, medial arm, and chest wall. If you experience burning, shooting, or electric-shock sensations, describe them in detail - this is a distinct and ratable condition separate from the structural mastectomy rating.

80%

Radical mastectomy of both breasts. Radical mastectomy means removal of the entire breast, underlying pectoral muscles, and regional lymph nodes up to the coracoclavicular ligament.

From 38 CFR: Under DC 7626: Following radical mastectomy - Both breasts: 80%. VA defines radical mastectomy as removal of entire breast, underlying pectoral muscles, and regional lymph nodes up to the coracoclavicular ligament.

60%

Modified radical mastectomy of both breasts. Modified radical mastectomy means removal of the entire breast and axillary lymph nodes in continuity with the breast.

From 38 CFR: Under DC 7626: Following modified radical mastectomy - Both breasts: 60%. VA defines modified radical mastectomy as removal of entire breast and axillary lymph nodes (in continuity with the breast).

50%

Either: (1) Radical mastectomy of one breast, OR (2) Simple/total mastectomy or wide local excision with significant alteration of size or form of both breasts.

From 38 CFR: Under DC 7626: Following radical mastectomy - One breast: 50%. OR Following simple mastectomy or wide local excision with significant alteration of size or form - Both breasts: 50%.

40%

Modified radical mastectomy of one breast - removal of entire breast and axillary lymph nodes in continuity.

From 38 CFR: Under DC 7626: Following modified radical mastectomy - One breast: 40%.

30%

Simple/total mastectomy or wide local excision with significant alteration of size or form of one breast.

From 38 CFR: Under DC 7626: Following simple mastectomy or wide local excision with significant alteration of size or form - One breast: 30%.

0%

Wide local excision (lumpectomy) of one or both breasts WITHOUT significant alteration of size or form. Important: Residuals such as scars, lymphedema, or functional impairment must still be rated separately under appropriate diagnostic codes.

From 38 CFR: Under DC 7626: Following wide local excision without significant alteration of size or form - Both or one: 0%. Note: This is a noncompensable rating for the structural change only. Residuals (scars, lymphedema, range of motion loss, grip loss, sensory loss) must be rated under appropriate separate diagnostic codes.

Surgical Type and Extent

How to describe it: Clearly state the exact type of surgery you underwent using precise terminology: 'I had a modified radical mastectomy of my left breast, which involved removal of the entire breast and axillary lymph nodes.' Bring operative reports or a summary to ensure accuracy.

Example: I had a modified radical mastectomy of my left breast. The surgeon removed the entire breast and all axillary lymph nodes. I have a long scar across my chest and into my armpit, and I wear an external prosthesis because reconstruction was not an option for me.

Examiner listens for: The examiner needs to categorize your surgery precisely under VA definitions to assign the correct rating tier. The distinction between radical, modified radical, simple, and wide local excision directly determines your baseline percentage.

Avoid: Do not say 'they just removed some tissue' or 'I had a small surgery.' Be specific. If you had a 'lumpectomy,' clarify whether it significantly changed your breast size or shape, because that distinction separates a 0% rating from a 30% rating.

Significant Alteration of Size or Form

How to describe it: If you had a lumpectomy or simple mastectomy, describe concretely and specifically how your breast size or shape changed: asymmetry, indentation, volume loss, skin retraction, or nipple displacement. Use objective comparisons (before vs. after photos if available, bra size changes).

Example: Before my lumpectomy, both breasts were the same size. After surgery, the affected breast lost so much tissue that it is noticeably smaller - I have to use a padded bra insert to look symmetrical. There is a visible indentation where the tissue was removed, and my nipple is pulled to the side.

Examiner listens for: Whether the surgery caused a 'significant' change in breast size or form is a critical distinction that separates a 0% rating from a 30% rating. The examiner must document objective findings of size or shape change that go beyond a minimal scar.

Avoid: Do not say 'it looks mostly normal.' If there is visible asymmetry, indentation, skin retraction, or nipple displacement, describe it clearly. Bring before-and-after photos if available.

Lymphedema Symptoms

How to describe it: Describe the swelling location (hand, forearm, upper arm, chest wall), how it fluctuates throughout the day and with activity, whether you wear a compression garment, and any infections (cellulitis) you have developed. Rate the heaviness and tightness you feel.

Example: On my worst days - usually after I've been active or when it's hot - my entire left arm swells from my hand to my shoulder. My arm feels like a log: heavy, tight, and stiff. I can't make a fist or type for more than 10 minutes. I've been hospitalized twice for cellulitis in that arm, which required IV antibiotics.

Examiner listens for: Severity, frequency, functional impact, and complications of lymphedema. The examiner must document this as a ratable residual under DC 7626 notes and potentially under additional diagnostic codes for upper extremity functional impairment.

Avoid: Do not say 'it's just a little puffy.' Lymphedema that requires compression garments, limits activity, or has caused infections is moderate-to-severe and should be described as such.

Arm and Shoulder Functional Limitation

How to describe it: Describe specific activities you can no longer do or do with difficulty: reaching overhead, lifting, carrying groceries, fastening a bra, driving, computer work. Quantify limitations: 'I cannot lift more than 5 pounds with my left arm without significant pain and swelling.'

Example: On bad days, I cannot raise my left arm above shoulder height at all due to pain and tightness from radiation fibrosis and lymphedema. I cannot carry anything heavier than a gallon of milk in that arm. I had to stop working in my garden because of the strain it causes. I wake up at night from the pain.

Examiner listens for: Concrete, measurable functional limitations that correlate with range of motion findings and DeLuca factors - especially how function changes with repetitive use, activity, or flare-ups.

Avoid: Do not say 'I manage' or 'I've gotten used to it.' If you have limited your activities to avoid pain or swelling, describe what you no longer do and why. The DeLuca standard requires that impairment during actual use be documented.

Scar Pain and Disfigurement

How to describe it: Describe the scar location, length, and characteristics. Describe pain quality (burning, stabbing, aching, hypersensitivity to touch or clothing), frequency (constant vs. intermittent), and triggers. Note any keloid formation, skin tightness, or restricted movement from scar tissue.

Example: My mastectomy scar runs from my sternum to my armpit, about 10 inches long. The scar itself burns constantly - a 6 out of 10 on a good day. On bad days, even a light touch from my shirt is unbearable. The scar tissue has pulled tight under my arm, which limits how far I can raise my arm. I sleep on the opposite side because lying on that area is too painful.

Examiner listens for: Pain, tenderness, restricted movement from scar, disfigurement, and whether the scar has characteristics of a painful or unstable scar warranting a separate rating under DC 7804.

Avoid: Do not minimize scar symptoms as 'normal healing.' Chronic scar pain that affects sleep, clothing choices, and daily function is ratable. Make sure the examiner documents that the scar is painful on palpation.

Neuropathic Pain and Sensory Loss (Post-Mastectomy Pain Syndrome)

How to describe it: Post-mastectomy pain syndrome (PMPS) involves chronic neuropathic pain in the chest wall, axilla, and inner arm from nerve injury during surgery. Describe burning, shooting, electric-shock, or allodynia symptoms. This is distinct from scar pain and should be described separately.

Example: I have constant burning and shooting pain that starts in my armpit and goes down the inside of my arm to my elbow. Sometimes it feels like an electric shock. The skin on the inside of my upper arm is numb in one area but hypersensitive in another - even a light breeze across it causes sharp pain. This never goes away; it's been present every day since my surgery.

Examiner listens for: Symptoms consistent with intercostobrachial nerve injury or other peripheral nerve involvement from axillary dissection. These are specifically listed ratable residuals under DC 7626 notes and may also be separately ratable under peripheral nerve diagnostic codes.

Avoid: Do not lump neuropathic pain together with general 'soreness.' Describe it as a distinct, separate set of symptoms with a specific location, quality, and pattern. Many veterans fail to report PMPS, leaving a significant ratable condition undocumented.

Treatment Status and Ongoing Therapies

How to describe it: Clearly state whether your cancer treatment is complete, ongoing, or in a watchful-waiting phase. List all current treatments: hormone therapy (tamoxifen, aromatase inhibitors), targeted therapy, radiation history, chemotherapy history, and any current physical therapy for lymphedema or range of motion.

Example: My cancer treatment ended three years ago. I am currently on anastrozole (aromatase inhibitor), which causes significant joint pain throughout my body, especially in my hands and knees. I see my oncologist every six months. I completed 16 radiation treatments that have caused permanent skin thickening and fibrosis of my shoulder area.

Examiner listens for: Whether the veteran is still in active treatment (which can trigger the active malignancy evaluation pathway), the extent of treatment-related residuals (radiation fibrosis, chemotherapy neuropathy, hormone therapy side effects), and the overall disease course.

Avoid: Do not omit current medications or assume 'I'm done with treatment' means you have no ongoing residuals. Hormone therapy side effects (joint pain, bone loss, cognitive effects) and radiation late effects are ratable residuals even years after treatment.

Impact on Daily Life and Occupational Function

How to describe it: Describe specifically how your breast surgery residuals affect your ability to work, perform household activities, exercise, sleep, and engage in social activities. Use concrete examples and quantify impairment where possible.

Example: My lymphedema and shoulder limitation forced me to leave my job as a dental hygienist because I could no longer hold my arms in the required positions for extended periods. At home, I cannot carry laundry, vacuum, or lift my grandchildren. I have not been able to sleep on my left side since the surgery. I require help with some personal care tasks because reaching across my body is painful.

Examiner listens for: Functional impairment that corroborates the physical findings. The DBQ has a specific section requiring the examiner to describe the impact of the condition on daily occupational and daily activities - this information comes directly from what you tell them.

Avoid: Do not say 'I've adapted.' Adaptations are evidence of limitation, not normalcy. If you've changed jobs, hired help, stopped hobbies, or reorganized your home due to your condition, describe these adaptations explicitly as evidence of functional loss.